Chapter 3. Adrenalectomy

General Indications

• Clinically or biochemically apparent adrenal hormonal hyperfunction.
• Possible or certain malignant adrenal mass.
• Adrenal mass of uncertain significance.

Specific Conditions and Disease States

• Primary hyperaldosteronism.
  • Unilateral cortical adenoma causing Conn's syndrome.
  • Bilateral hyperplasia with unilateral dominance (established by adrenal vein sampling).
• Hypercortisolism.
  • Unilateral cortical adenoma.
  • Refractory Cushing's syndrome (from Cushing's disease, primary adrenal hyperplasia, or ectopic adrenocorticotropic hormone [ACTH] syndrome).
• Pheochromocytoma.
• Unilateral cortical adenoma causing virilization.
• Myelolipoma (in selected situations).
• Adrenal cyst (if refractory or symptomatic).
• Adrenocortical carcinoma.
• Incidentaloma with indeterminate or concerning imaging characteristics.
• Adrenal metastases of other primary cancers (in selected situations).

Laparoscopic Adrenalectomy

Absolute

• Adrenocortical carcinoma (certain or likely).
• Refractory coagulopathy.
• Comorbidities precluding safe general anesthesia.

Relative

• Previous ipsilateral partial adrenal resection.
• Previous extensive upper abdominal or retroperitoneal surgery.
• Very large adrenal tumors (> 6–8 cm).
• Suboptimal medical preparation for pheochromocytoma resection.

Open Adrenalectomy

Absolute

• Refractory coagulopathy.
• Comorbidities precluding safe general anesthesia.

Relative

• Suboptimal medical preparation for pheochromocytoma resection.

Laparoscopic Adrenalectomy

• General anesthesia is induced with the patient supine.
• An orogastric tube and a Foley catheter are placed.
• The patient is placed in the lateral decubitus position with the ipsilateral side up.
• The table is gently flexed to widen the angle between the costal margin and iliac wing.
• An axillary roll is placed and a beanbag used to hold the patient in position.
• Arms, head, and legs are appropriately padded and not abducted beyond 90 degrees.

Open Adrenalectomy

• A nasogastric tube and a Foley catheter are placed.
• The patient is placed supine with his or her arms resting on arm boards and with legs padded.

• Incentive spirometry should be used to prevent atelectasis and postoperative pneumonia.
• Laparoscopic procedures often require less fluid replacement than do open procedures.
• Postoperative DVT prophylaxis should be maintained until the patient is ambulatory.
  • Ambulation should be encouraged as early as possible.
  • Following laparoscopic procedures, subcutaneous heparin prophylaxis is appropriate if no concerns exist about ongoing bleeding.
• Early resumption of regular diet should be possible.
• The Foley catheter may be discontinued once hemodynamics, urinary output, and electrolytes are stable and within the normal range.

Patients with Hyperaldosteronism

• Potassium supplementation should be stopped immediately postoperatively.
• Antihypertensives should be weaned.
• Electrolytes, including potassium, should be checked the morning after surgery.

Patients with Pheochromocytoma

• Patients should be monitored for signs of postoperative hypotension resulting from vascular relaxation.
  • Significant intravenous fluid resuscitation or pressors may be required, although this is less of a problem following adequate α blockade.
• α Blockade may be discontinued ...